following the process of care management. speaker bio gary m. austin, vp-nhii solutions, practice...
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Speaker Bio• Gary M. Austin, VP-NHII Solutions, Practice Lead, MA/NY/PA based
– Formerly BCBSMA, Director IT Strategy and Health Mgmt Systems• eRx Collaborative principal ($4m payer investment in eRx)• Project Director, MA-SHARE MedsInfo project (Rx Payers to ED)• Mass eHealth Collaborative thought leader ($50 million payer
investment in EMR)• eRx for Homeless project director
– Speaker, HIT, NMHCC, DMC, TEPR, WEDI and other conferences on Payer Involvement in RHIO’s
– Leading MEDecision’s RHIO pursuits in over 30 markets– Previous lives at:
• Payers: Excellus, CIGNA, Preferred Care, Providence Healthcare• Delivery Systems: SHARP, St. Luke-Shawnee Mission, The Health
Alliance• Nothing to do with Healthcare: Rolls-Royce aerospace, Automotive
Network Exchange, British Petroleum, Marine Midland (Hong-Kong Shanghai) Bank
About MEDecision• MEDecision is the software leader in Collaborative Care Management.
Founded in 1988, the company’s Integrated Medical Management solutions create a seamless payer-based medical management system to analyze, apply, administer and automate management of healthcare programs and provide a common patient view at the point of care.
• MEDecision’s clients include 21 of the country’s Blue Cross BlueShield plans and over 40 other payer clients -- improving patient outcomes, reducing medical errors, and increasing operational efficiencies for approximately one in every six (43 million) Americans.
• Client list includes:– BCBS Plans
• Anthem CareFirst HCSC• Massachusetts Michigan Excellus
– Medicaid Plans• Keystone-Mercy (PA) Avidyn KeyPro
– IDN’s• Fallon (MA) Scott & White NY
Presbyterian
Assumptions Behind DE PCS Project
• Payers and providers can work together to improve patient outcomes by supplementing provider electronic medical records with payer member information
• Payers can jumpstart RHIO efforts by pre-populating electronic health records systems with payer-based health record (PBHR) information
Christiana Care-BCBSD Project
• Payer-provider collaboration to share multi-source patient data at point of care
• One-year pilot to test impact and establish evaluation criteria
• Common goals:– Improved patient care through better
information– Lower costs through reduced duplication and
improved outcomes
Collaboration for ImprovedPatient Care
CCHS
MEDecision
BCBSD
Patient data from all providers
CCHS Emergency
RoomData on patients treated within the Christiana system
“Integrated Medical Management”
Patient Eligibility
Patient Clinical Summary
Patient SummaryReport
Phase 1
Collaboration for ImprovedPatient Care
CCHS
MEDecision
BCBSD
Patient data from all providers
CCHS Emergency
Room
Integrated patient recordaccessed at point of care
“Integrated Medical Management”
Patient Eligibility and Patient Summary Report
Consolidated Patient Clinical
Summary
Patient SummaryReport combined with
Patient Clinical Summary
Other Regional Payers
Follow-on Phases
The Provider Viewpoint
Christiana Care Health System
• Largest provider in Delaware– Also serving portions of PA, MD, NJ– 2 hospitals, plus multiple services– Half of all admissions in DE
• 92,000+ ED visits annually– 17th busiest nationwide
• Level I regional trauma center with 2600 admissions annually
Background
• Collaborated with ED in 2003-04 to improve information flow– Huge repository of clinical information (e.g.,
lab and radiological data to 1992)• Created “Patient Summary Report”
– Patient demographics– Last 5 hospital visits and diagnosis– ER visits– Last 5 lab and radiology visits– Last 10 physician visits
Background (cont’d)
• Patient Summary Report automatically printed when patient registers at ED
• ED personnel note reduction in duplicate tests
• After 6 months, limitations were obvious
• Need for more information sources– Pharmacological view– Other providers and procedures
Basis for Improvements
• MEDecision’s PCS similar to CCHS PSR
• BCBSD adds patient data from physicians, pharmacies, imaging centers, etc.
Christiana Care:“deep”
BCBSD:“broad”
+
Expectations
• Improved decision-making
• Reduction in preventable errors
• Higher quality of care plus greater safety
• Cost savings through reduced duplication
• “Why not us?” from other providers
• A preview of what DHIN can accomplish
The Payer Viewpoint
Why Get Involved?
• Patient safety: expectations amongst patients and accounts that we are trying to improve the safety of the care provided
• Cost containment
• NCQA accreditation
• Improved relations with major providers of care
• Incubator for other ways to share data
Why? (cont’d)
• Christiana Care an attractive partner– Academic rigor– High-volume Level I trauma center– High overlap with BCBSD
• ER best site for proof of concept– Controlled setting and access– Most likely to deliver ROI from reduced
duplication
Payer Concerns
• HIPAA and patient privacy
• Concerns of BCBSD– Data may not be current– Claims history file may not contain all details
• Project costs and ROI– Capital and operating expenses– Personnel and training– Measurement criteria
Some Prospective Metrics
Utilization Statistics
• 25,257 total ED visits during CY 2004
• 10,922 ED visits resulted in lab testing being performed
• Total cost of lab tests $5.8 million
• 12,192 ED visits resulted in a radiological examination
• Total cost of radiology tests $6.1 million
Utilization Prior to ED Visit
• 425 doctor visits had a lab test within 30 days of the ED visit
• 296 doctor visits had a lab test within 14 days of the ED visit
• 598 doctor visits had a radiological examination within 30 days of the ED visit
• 457 doctor visits had a radiological examination within 14 days of the ED visit
Utilization After ED Visit
• 811 doctor visits had a lab test within 30 days after the ED visit
• 574 doctor visits had a lab test within 14 days after the ED visit
• 2,582 doctor visits had a radiological examination within 30 days after the ED visit
• 2,043 doctor visits had a radiological examination within 14 days after the ED visit
Measuring Success
• ED staff satisfaction– Was the data valuable?
• Member satisfaction
• ROI calculations
Vendor Perspective
The Electronic Health RecordPersonal
Health Record (PHR)
Electronic Medical
Record (EMR) Payer Based Health Record
(PBHR)
PHREMR
PBHR
Electronic Health Record
“EHR”
EHR = PBHR + EMR + PHR
Leveraging Payer Data• The PBHR is one component of a comprehensive Electronic
Health Record (EHR)• The PBHR is a clinically useful summary based upon data the
payer holds – demographic, claims, care management, Rx, Labs, risk analysis, etc.
• Data is aggregated, sanitized, and presented to the clinician• Clinical rules highlighting gaps in care, care opportunities and
the like can be overlaid, yielding the Patient Clinical Summary (PCS)
• Clinical data can also be included as you mature the system• MEDecision KNOWS payer data as well as any company in
the industry; it is forming “data alliances” with data owners and clinical systems companies in a drive to deliver comprehensive EHRs
A Payer RHIO Win!
• Utilize the Payer-based Health Record (PBHR) as a launch strategy– Turn on payers in a market one at a time– Initial delivery to high cost delivery sites such as hospital ED’s– Subsequent delivery to ambulatory providers– Speed to Value: ≈ 90-120 days following receipt of clean data
from plans– Clear public, payer, and clinical value– Low risk (payer data), low cost (by the drip), low complexity
(ASP and web)
• A wonderful public story; Betty came into the ED unconscious…
Sample Preliminary ResultsFrom Retrospective Study
Study Methodology
• Inclusion Criteria:
Registered in the CCHS ED on or after 2/1/2005
Triage severity level 1 or 2
(scale 1 to 5, 1 = most severe)
Verified as BCBSD members• Sampling Strategy:
The patients were sorted in order of registration date and 59 consecutive patients meeting the above criteria were selected.
The Study
• 59 consecutive BCBSD patients
• High triage severity
• Compare completeness of medication record (ED admission medication records compared to Payor PBM claims)
Review Outcome
48%
42%
10%
Payor Info > EDPayor = EDED Info > Payor
Other Interesting Observations
• Patients with chest pain in the ED who had already received a full cardiac workup and EGD within the last 6 weeks
• Patients with asthma who had no claims for home nebulizer therapy
• The most severely ill patients had the greatest number of missing medications
• Trauma patients unknown to be taking anti-platelet or anticoagulant medications
• Patients with symptomatic coronary artery disease taking Viagra
• More To Come…
Edward Ewen, Jr, MDDirector of Clinical Infomatics, CCHS
“In an emergency setting alone it appears this information could significantly impact
medical decision-making and clinical outcomes”
The Moral of the Story…
